The next frontier in “integrative medicine”: Getting Medicaid to fund quackery

Well, I’m back.

I didn’t realize it until New Year’s Day, but it has been nearly two weeks since I last wrote a post that was about anything other than puppies. Of course, my traffic would probably be very much higher if all I wrote about is fostering puppies and how outrageously cute they are, but that’s not what I’m about. Also, the puppies will be heading to the shelter on Sunday to be put up for adoption. I expect they’ll go fast to good forever homes, and I will deeply miss the little buggers.

It is the dawn of a new year, and in early January my thoughts, as is the case for many people, often turn to what sorts of tasks and plans I need to do and develop for the year ahead. Last year, as is the case with most years, had a lot of pseudoscience and quackery to deal with, including the horrible news that Susan and Henry Samueli donated $200 million to the University of California, Irvine to establish an integrative medicine program that will likely be larger than any in the world, a potent force to “integrate” pseudoscience and quackery into medical schools. On the other hand, the year ended with the FDA releasing proposed regulatory guidance on homeopathy that would (finally!) regulate homeopathic remedies as drugs, leading me to ask if 2018 would finally be the year when this happens. I certainly hope so.

However, on December 31, I saw a rather disturbing story that tells me that those of us supporting science-based medicine still have our work cut out for us. I also found it disturbing because I lived in Cleveland for eight years. Even though I havne’t lived in Ohio for 20 years, my wife and I still have friends there, and we still have an attachment to the state given that my wife’s family is from northwest Ohio. Basically, Ohio is opening up its Medicaid program to acupuncture quackery:

Starting January 1, more than 108,000 Ohioans on Medicaid who have diagnosed low back pain or migraines will be able to see an acupuncturist for pain management. The change in policy is part of an effort to reduce the number of unnecessary opioid prescriptions and overdose deaths in the state that arise from treating chronic pain with addictive drugs.

For the past year, Ohio has been one of six states in the country to cover acupuncture treatments for Medicaid patients, but only when offered by a doctor. Starting tomorrow, Medicaid reimbursement will be open to licensed non-physician acupuncturists who register as Medicaid providers.

The agency hopes that expanding access to the treatment, a centuries-old pain-relief technique that involves inserting hair-thin needles into the skin at specific points, will save money over time on addiction treatment and other costs related to opioid use.

Practitioners and their patients say it’s about time more people had access to the proven and safe, but expensive, non-drug therapy, and that more insurers should follow suit.

The opioid crisis is the new “wedge” being used by promoters of “integrative medicine” quackery, who are taking advantage of the search for non-opioid and non-pharmacologic treatments for chronic pain to promote their placebo-based pseudoscience as the solution to the crisis. It’s become one of the main talking points used by advocates to open the door for the “integration” of mystical, prescientific, and pseudoscientific treatments like acupuncture into medicine. Indeed, whenever you hear the terms “non-drug therapy” or “nonpharmacologic management of pain” used by advocates with respect to the opioid crisis and chronic pain management, it’s code for placebo-based quackery. The quacks are not even subtle about it.

It’s a rationale that comes right from the top, from the most prominent proponents of “integrative medicine.” For instance, the National Center for Complementary and Integrative Health (NCCIH) featured the opioid crisis as a compelling reason for its existence in its latest five year strategic plan, which made the “nonpharmacologic management of pain” one of its top research priorities. Since then, NCCIH has been promoting such approaches, science-based or quackery like acupuncture, as its own, the better to seamlessly integrate pseudoscience with science. Elsewhere, the same sort of rationale is used to justify the introduction of quackery into the VA medical system, while even prestigious journals like The BMJ and JAMA buy into the message. Even the FDA is considering encouraging knowledge about chiropractic and acupuncture as approaches for chronic pain.

It’s not just NCCIH, either. There are professional societies jumping on the bandwagon as well. For instance, the American College of Physicians included acupuncture on its list of recommended strategies for low back pain. An entire professional organization, the Society for Integrative Oncology, is devoted to diluting the science of oncology with a mixture of lifestyle interventions that are in no way “alternative” or “integrative” plus pseudoscientific nonsense. Even NCI-designated comprehensive cancer centers like Memorial Sloan-Kettering Cancer Center are increasingly “integrating” quackery with oncology. And don’t even get me started on “naturopathic oncology,” which is becoming increasingly accepted and metastasizing outside of academia.

Meanwhile, back in Ohio:

Dr. Maya Myslenski, a pediatrician who practices in the emergency department at MetroHealth Medical Center, has been offering acupuncture to her patients for a variety of ailments for more than two years. It helps patients with both acute and chronic pain, anxiety, and some stomach ailments, she said.

“A lot of our [Medicaid] patients can’t afford to go to private offices for treatments,” Myslenski said. “I’m beyond thrilled about treatments being covered for them.”

Noooo! During my residency at University Hospitals of Cleveland, I did part of my training at MetroHealth Medical Center, particularly for trauma. I moonlighted as a helicopter flight physician for Metro LifeFlight, which is based at MetroHealth Medical Center.

Unfortunately, this article is quite credulous about acupuncture, repeating the usual tropes used to justify it:

In Ohio, the move to cover acupuncture for chronic pain conditions began in earnest in January of 2016, when Gov. John Kasich’s Cabinet Opiate Action Team (GCOAT) released a guideline for the management of acute pain outside of emergency departments. The guideline said that non-drug therapies such as acupuncture (as well as physical and massage therapies, biofeedback and hypnotherapy) should be considered as first-line treatments for acute pain. The Governor’s team also encouraged Medicaid to further research and review acupuncture.

Then in January of 2017, the Joint Commission, the not-for-profit organization that certifies hospitals have met certain safety standards, changed its pain management standards to require that accredited hospitals provide nonpharmacological pain treatments.

Around the same time, the American College of Physicians issued new guidelines for the treatment of low back pain, which recommended that doctors treat patients with non-drug therapies first, including acupuncture.

One more time: The ACP guidelines were poorly conceived and based on weak science. I’ve also mentioned the Joint Commission’s recommendations before. While it’s not unreasonable to promote the use of nonpharmacological approaches to pain, those approaches must be science- and evidence-based. So far, advocates of unscientific approaches like acupuncture have been getting away with using the opioid crisis as a cover to advance their quackery and even get the government and insurance companies to pay for it. They’re not even subtle about it:

“It may take another year or so, but I do think it’s going to lead to a change in policy,” he said. “The opioid crisis has helped the establishment catch up a little to research on acupuncture. There’s been a big change in attitude in terms of openness to this sort of thing.”

The person making the above statement is Robert Davis, a Vermont acupuncturist who led the state’s pilot testing acupuncture for back pain. Yeah, that gives me a lot of confidence in the scientific validity of the pilot studies being done in various states. I note that his website basically relies on testimonials to claim that acupuncture “works”; well, that and “ample clinical experience, supported by some research data.”

I also can’t help but note that even the author of this story lazily cites a “meta-analysis” from the Australian Acupuncture and Chinese Medicine Association that was not published in any peer-reviewed journal as “evidence” for the efficacy of acupuncture, as he lays down quotes like:

West said the research on acupuncture has become much clearer in recent years, both on how well it works and how it can save money.

“There are some really big, recent studies that clearly show that acupuncture is not only comparable to Western medicine in how effective it is, but it’s safer and it’s cost-effective,” West said. “In chronic low back pain, you can save money over the long-term, give people just as good care and they’re not getting addicted to pain medication.”

It costs the insurer between 70 cents and $1 per month, per policy, to add acupuncture coverage, West said. “It just doesn’t make sense not to when we’re spending $1 billion a year in Ohio on addiction treatment.”

No, when you’re spending $1 billion a year on addiction treatment for Ohio residents, it doesn’t make sense to waste money on ineffective and pseudoscientific treatments. What’s next? Narconon? Also, no, there are not “really big, recent studies that clearly show that acupuncture is comparable to “Western” medicine, much less cost effective. In general, most studies of acupuncture tend to be relatively small, poorly controlled, and equivocal in results, while meta-analyses of acupuncture studies are generally the epitome of “garbage in, garbage out.” In general, the larger and better designed the acupuncture study, the smaller the effect, with the effect size being in essence zero in the very best studies. Moreover, it doesn’t matter where you place the needles or even if you place the needles in; the effect is the same, nonspecific. Acupuncture doesn’t work. It is theatrical placebo.

As for Jared West, who was quoted above, he’s an acupuncturist, of course. Not surprisingly, he offers acupuncture, moxibustion, and cuppingquackery. He’s also president of the Ohio Association of Acupuncture and Oriental Medicine and is helping providers navigate the Medicaid registration process and has advised the state on reimbursement and other issues.

And now Medicaid in Ohio will pay for it, but it’s not only Ohio. Six states thus far cover acupuncture under their Medicaid program, California, Oregon, New Jersey, Massachusetts and Minnesota, with Maine and Vermont considering whether to cover the treatment for their Medicaid patients after completing pilot studies testing its effectiveness, largely, it appears, based on popularity:

“We had a waiting list in pretty short order,” said Davis. Pain, sleep disturbance, fatigue, functioning, depression and anxiety all improved for patients in the pilot study, he said. While historically most people who use acupuncture as a treatment have had higher-than-average income and education levels, the Vermont study suggests this is only because they’re the ones who could afford it, Davis said.

One wonders if this pilot study had a control group. My guess is that the answer is no. My guess was correct, it turns out. This pilot study was a “pragmatic trial,” with no blinding and no control group. As I’ve pointed out time and time again, acupuncturists love pragmatic trials, because they allow placebo effects to appear to be real effects.

In 2018, look for more of this. Just like naturopaths, acupuncturists are using the opioid crisis as an opportunity to legitimize their profession, the way that naturopaths are using the opioid crisis as a strategy to justify obtaining licensure in more states. Quacks, be they naturopaths or acupuncturists, are just like The Terminator in that they are relentless. They can’t be bargained with. They can’t be reasoned with. And they absolutely will not stop until science-based medicine is dead.